Cuts get personal

The Guardian 19 February 2011

As a long-term patient at St Bartholomew’s hospital in London I read this week’s news of cuts with trepidation. In order to meet the government’s £20bn NHS “savings” target, the trust that runs Barts and the Royal London in Whitechapel is to cut 635 jobs, including 258 nursing posts – 10% of the total. This despite repeated government pledges to protect frontline services. Yesterday the Guardian revealed similar cuts at other London hospitals.

The trust insists that none of this will affect patient care. To anyone who regularly uses Barts or the Royal London that’s an assertion so wildly improbable as to border on insult. Staff deliver an efficient, caring service, but they are already at their limits. There’s no slack.

Any big hospital is a complex and fragile mechanism. So much can go wrong at so many stages. Take the administration of a single dose of chemotherapy. Blood has to be taken, transported, analysed; therapies have to be prescribed, assembled, delivered. Whether it’s the nurse inserting the needle into the vein, or the pathologist measuring platelets, there’s no room for error. A break in the chain leads to a breakdown in care, or worse.

The process of administering that one dose of chemotherapy relies on tasks performed correctly and promptly by receptionists, nurses, technicians, porters, pathologists, pharmacists, clerical assistants, cleaners, IT experts, supplies managers – not to mention doctors. It relies equally on “backroom” and “frontline” staff. It’s as co-ordinated as a ballet or symphony orchestra, and I never cease to marvel that it works. But I also know that it’s vulnerable. There’s no way you can slash staff by 10% and not seriously compromise the organism.

Every one of the departments involved in that single chemo dose will be affected by staff cuts. Fewer people will be asked to deal with greater demand, and that must lead to more errors, more delays, more miscommunication, more aggravation for both staff and patient. As you sit on your IV drip, the last thing you want is the hospital falling apart around you.

Even more disturbing for patients, this round of cuts is not the end of the story, at Barts or across the NHS. As “social enterprises” competing in a healthcare market, hospitals will be under constant pressure to cut costs or increase income. If the government gets its way, my care will be commissioned by a GP consortium, which may or may not involve the excellent local clinic that referred me to Barts nearly four years ago. Decisions about what treatments to fund and who should provide them will not be made by the people who’ve been treating me but by the consortium, which may prefer to do business with another provider.

Patient involvement is a crucial component of effective treatment. It hasn’t always been easy to secure it in the NHS, but under the government’s plans it will be replaced by a “consumer choice” that leaves me no choice at all, that makes my care dependent on remote market forces and private interests.

Patients have benefited in recent years from a more integrated, multi-disciplinary approach to treatment, one based on information-sharing and an understanding of the complex nature of illness. The fragmentation of the NHS will make it harder for patients to benefit from this advance. In the course of my treatment I’ve made use of physiotherapy, radiotherapy, ameliorative care and dermatology specialists, to name only a few. How will these be co-ordinated when hospitals and specialist units are competing with each other, tempted to meet targets by avoiding responsibilities?

The government’s proposals spell the end of national collective bargaining in the health service and with it the breakup of the NHS career structure. I’ve seen many of my carers move on to more specialised or responsible jobs, and I know how important these prospects are to staff. They help keep them going and growing, and that is vital for patients.

In the future, hospitals like Barts will not be run for profit, but they will be run by profit. They will compete in a profit-governed marketplace, locked into dependence on the private sector to which they will turn for management and finance services. Hospitals will be under pressure to take more private patients. They will not be able to do that unless they offer something better to those who pay than they can get on the NHS. Preferential treatment is inevitable, and with it a two-tier environment in which the lower tier is starved of resources.

There’s a virtuous circle between patient and staff contentment; but under the stress of inadequate resources, job insecurity and inequalities in patient treatment, it can turn into a vicious one, with carers and patients in conflict.

The Trust aims to save £56m over two years. During those same two years, it will hand over nearly £200m (15.6% of its income) in repayments on an ambitious PFI project, including new cancer and cardiac centres – which will be completed just in time to find themselves chronically understaffed. Although the PFI dues were negotiated long before the financial crisis, they are considered sacrosanct, whereas a workable staff-patient ratio seems an optional extra.

Barts is one of Europe’s longest established providers of free medical care for the poor. From its 12th-century monastic founding through its years a City of London charity to its development as a modern NHS hospital, it’s sought to offer the best available care to Londoners. If the government’s plans proceed, it will not be able to do that.

Next door to Barts is the London office of investment bankers and “wealth managers” Merrill Lynch. At the end of a year in which the company was heavily embarrassed by the Irish banking collapse, it awarded its international boss, Thomas Montag, what appears to be the industry’s biggest bonus package, £10m, about the same amount “saved” by slashing the 258 nursing posts. Altogether, the bonuses paid out to top staff at Merrill Lynch could easily cover the entire cost of maintaining staff levels at both Barts and the Royal London. Merrill Lynch, of course, is only one of a number of City institutions within a stone’s throw of Bart’s which – unlike Bart’s – conspicuously failed in their duties to the public. If Barts made errors on the scale of the banks and investment houses it would have been closed down long ago.

Despite its prestige, its location and its excellent record, Barts is no more immune from cuts and privatisation than any other NHS hospital. It is not a special case but an all too typical example of what is happening elsewhere. If this process is to be arrested – and the life courses of a great many people depend on that – then the TUC’s demonstration on 26 March will have to be a powerful display of popular opposition to government policies, and specifically a show of determined support for the health service. This will be the best chance for patients and staff at hospitals across the country to make their voices heard. These “savings” will be made at our expense, and we simply cannot afford them.